Health Story: Progress Note

This page will support the development of the Progress Note Draft Standard for Trial Use (DSTU) for the October 2010 ballot cycle.

This project will design a Progress Note in XML as a constraint on HL7 v3 CDA r2. A Progress Note documents patient’s clinical status during a hospitalization or outpatient visit. The project will review current Progress Note usage and will examine industry precedents and requirements.

Recurring meeting: Tuesday @ 11:00 AM EST - 12:30 PM EST

Conference line: Phone Number: 770-657-9270 Participant Passcode: 310940

LiveMeeting: https://www.livemeeting.com/cc/dt/join?id=CDAconsolidation&role=attend

Draft IG and Sample

Draft DSTU and sample file pre-ballot -- This is a full draft ballot of all material discussed through 8/4.

Development

Progress Note Definitions

There are no accepted "standards" for what a progress note is in medicine. Implementations of EHRs display a very broad variety of structures for progress notes. A common structure is the "SOAP" format, but this is hardly the majority. The most commonly cited problem with the SOAP format is that is separates assessment from plan for a given problem, when it may feel more natural to discuss assessment and plan for each problem in turn. Furthermore, for consultants, "plan" may be an inappropriate section entirely, since they may feel they are limited to offering recommendations rather than plans. Additionally, there is disagreement as to whether patient-level data (like allergies or medication lists) should appear in progress notes or simply be referred to.

Mosby’s medical dictionary

Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. Progress notes may follow the problem-oriented medical record format. The physician's progress notes usually focus on the medical or therapeutic aspects of the patient's condition and care. The nurse's progress notes, although recording the medical conditions of the patient, usually focus on the objectives stated in the nursing care plan. These objectives may include responses to prescribed treatments, the ability to perform activities of daily living, and acceptance or understanding of a particular condition or treatment. Progress notes in an in-hospital setting are recorded daily. Those in a clinic or office setting are usually preceded by an episodic or interval history and are recorded as accounts of each visit.

Taber’s medical dictionary

An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. In patients who are not critically ill, a note concerning progress may be made daily or less frequently; for patients in critical care, notes may be made hourly. It is important that each note be clearly written, the date and time recorded, and the note signed.

University of Washington Internal Medicine Program

Proposes a criterion to judge the adequacy of a progress note: "Could I read this note and assume care of this patient? Reader can determine the patient’s current clinical status AND the team’s thinking about what’s going on and what is planned."

Header Review

General Header Sample XML
Header Comparison (includes H&P, OpNote, DS, and proposed Progress Note Headers)

Proposed heuristic for LOINC document codes: ALL LOINC codes that are evaluation and management doc codes identified as “subsequent evaluation notes”.
LOINC Codes for discussion (courtesy of FEI)

Body Review

Proposed Progress Note Sections

Sample Progress Notes (courtesy of MedEDocs)

Statistical Section Analysis (courtesy of M*Modal)

Health Story section crosswalk

College of Registered Nurses of British Columbia’s (CRNBC)- Practice Support- Nursing Documentation (pg 18)
Progress notes (nurses’ notes) are used to communicate nursing assessments, interventions carried out, and the impact of these interventions on client outcomes. In addition, progress notes are intended to include: client assessments prior to and following administration of PRN medications; information reported to a physician or other health care provider and, when appropriate, that provider’s response; all client teaching; all discharge planning, including instructions given to the client and/or family and planned community follow-up; all pertinent data collected in the course of providing care, including data collected through technology such as monitoring devices (e.g., strips produced during cardiac or fetal monitoring); and advocacy undertaken by the nurse on behalf of the client.

Reference Material

• Project Scope Statement
• Health Story project

Pertinent CDA Guides

• Care Record Summary (CRS)
• Consult Notes
• Discharge Summary
• History and Physical (H&P) Notes
• Imaging Integration; Basic Imaging Reports in CDA and DICOM (membership required)
• Operative Notes

Education

Quick Start Guides

• CDA Quick Start Guide (v1.5)

This Quick Start Guide supports implementers working with simple CDA documents. It covers required elements in the CDA header and body and explains fundamental concepts including the CDA approach to identifiers, vocabulary and data types.

• Continuity of Care Document (CCD) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Continuity of Care Document (CCD). If not already familiar with the underlying Clinical Document Architecture Release 2.0 (CDA R2) standard, readers should also take advantage of the CDA Quick Start Guide available here.

• Care Record Summary (CRS) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Care Record Summary (CRS).

Agendas and Meeting Minutes

• DSTU ballot prep meeting minutes 8/10/2010
• DSTU review meeting minutes 8/3/2010
• Review of section cardinality meeting minutes 7/20/2010
• Review of Header constraints in IG Header and section proposals meeting minutes 7/13/2010
• Header wrap-up and section analysis meeting minutes
• Header design and initial section analysis meeting minutes 6/29/2010
• Header design meeting minutes 6/22/2010
• Kickoff meeting minutes 6/16/2010